Foot In diabetes UK

Attending a NICE stakeholder workshop for peripheral arterial disease

NICE - Why Peripheral Arterial Disease?

The National Institute of Clinical Excellence (NICE) produces national guidance for the NHS in England and Wales, focussing on a combination of clinical and cost effectiveness. The guidance can be used by a broad range of people; clinicians, teams, managers or commissioners, to guide them in the best use of the resources they are responsible for. Peripheral arterial disease (PAD) is a significant, often under-diagnosed and under-managed long term condition, common in the adult population of the UK, which if not identified and managed early results in avoidable morbidity and mortality such as heart attacks, strokes and amputation.

NICE has commenced the process of developing guidance on peripheral arterial disease. A broad range of stakeholders have been encouraged to become involved in the process to ensure it is as robust and inclusive as possible. This started with a stakeholder workshop held in London in May 2010. I attended as a representative of Foot in Diabetes UK (FDUK), which has registered as a stakeholder.

The NICE Stakeholder Workshop
The NICE team steered us through the process of how NICE develops and produces its guidance and technical appraisals. They clarified specific aspects such as the evidence reviews, the role of guideline development groups, the rationales for the scope and exclusions from guidance and the involvement of patients and public, as well as clinicians and other stakeholders.

The main workshop session involved mixed groups of stakeholders debating the draft scope to see if it looks balanced, prioritised and inclusive of the important evidenced areas of PAD. Stakeholders included Vascular Consultants, Clinical Researchers, Specialist Nurses, Radiologists, patient representatives, representatives of Professional Bodies e.g. Vascular Society, health economists, commercial companies and others. Debate focussed on issues such as defining severity of PAD, recognition of urgent vs. non-urgent PAD, initial first line diagnosis, medical, lifestyle and surgical interventions, endovascular interventions not just being a simple comparison to bypass surgery in the PAD pathway, the concept of amputation as an intervention, rather than just an outcome and many more subtleties. The facilitator kept us to the objective of the session – to refine the draft scope, form key queries to be dealt with in the final guidance and steered us professionally through 2 quick and stimulating hours.

Specific points FDUK raised / lobbied on at the NICE PAD scoping workshop

• Inclusion of a Podiatrist with a vascular remit on the suggested Guideline Development Group, along with other key clinicians already listed
• Inclusion and clarity re first line non-invasive diagnostics – history taking, symptom questioning, pulse palpation and use of handheld Doppler
• Importance of inclusion of recognition and timely action with both critical limb ischaemia and acute limb ischaemia
• The importance of reviewing evidence and the NICE position on asymptomatic PAD
• Reviewing evidence on the best palliative management of ischaemic rest pain, where surgery is not possible / declined

The next phase in NICE Guideline development

The next phase is that the NICE team accommodate the output from today’s’ workshop into a revised version of the draft scope, this goes out to the stakeholders for comment and then the work of the Guideline Development Group begins – which is about building all the important detail and clarity onto the agreed scope, critiquing the revised draft and following it through to completion, before as always, the vital task of implementation begins. In 2012, the NICE guidance on PAD is expected to be published.

Through the NICE guidance, this ‘Cinderella’ aspect of cardiovascular disease is finally going to get the high profile and the attention it duly deserves, to help the NHS effectively treat and minimise the associated poor avoidable outcomes, which are all too common currently some areas of England and Wales.

Martin Fox
Vascular Podiatrist, NHS Manchester
Foot in Diabetes UK (FDUK)
May 2010